The Shoulder. Jill Inouye Primary Care Sports Medicine Family Medicine Resident School February 26, 2014

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1 The Shoulder Jill Inouye Primary Care Sports Medicine Family Medicine Resident School February 26, 2014

2 Objectives Review shoulder anatomy Explain and demonstrate shoulder physical exam Diagnosis and management of common problems Rotator cuff tears/tendinopathy Impingement Adhesive capsulitis Labral tears

3 Anatomy 3 bones: Scapula Clavicle Humerus 3 joints: Acromioclavicular Glenohumeral Sternoclavicular

5 Anatomy Glenohumeral joint: shallow ball and socket Allows greater ROM but less stability rotator cuff muscles help to stabilize Supraspinatus: abduction Subscapularis: internal rotation Infraspinatus: external rotation Teres minor: external rotation 17 muscles attach to the scapula to assists in stability

8 Physical Exam History Inspection Palpation Active vs. passive ROM Strength testing Neurovascular testing Special tests thewinger.com

9 Physical Exam Inspection: Need to see both shoulders and compare If patient is very uncomfortable or has acute trauma, may need x-rays first Keep neck, elbows, wrists, and hands in mind Palpation: clavicle, AC joint, scapular spine

10 Range of Motion and Strength Abduction supraspinatus Empty and full can tests External rotation infraspinatus and teres minor Lag test Internal rotation subscapularis Lift off test and belly press test Elbow flexion and supination biceps

11 Special Tests Rotator cuff: strength tests Drop arm and empty/full can Impingement: Neer and Hawkins Labral tear: Crank and O Brien Instability: Apprehension, Relocation, and sulcus AC joint: cross over Biceps: Speed s and Yergason s

13 Case 1 70 year-old retired male who comes in with right shoulder pain for 2 months He was reaching behind while driving and his shoulder got twisted Limited active ROM due to pain with abduction, flexion, and external rotation but normal passive ROM 4/5 strength in right shoulder Pain relief and good strength after lidocaine injection

14 Rotator Cuff Injury Repeated abduction and flexion wear and tear on tendons as it rubs against acromion and coracoacromial ligament Supraspinatus is more common Risk factors: Repetitive overhead activities and overuse Weakness or fatigue of RC or supporting muscles Instability or hypermobility Trauma Older age

15 RC Injury History: pain with overhead activities; pain at night; possible weakness Physical exam: May have atrophy and sunken appearance Asymmetric motion Painful ROM and possible weakness above 90 degrees of abduction, internal rotation, and external rotation Passive ROM is usually greater than active ROM Tenderness over affected muscles and/or subacromial area

16 RC Injury Lidocaine injection test: subacromial injection of lidocaine Pain relief and normal strength = tendinopathy Persistent weakness = larger tear Imaging: x-ray usually not helpful but may show elevated humeral head if chronic commons.wikimedia.org

17 RC Imaging MSK ultrasound thought to be gold standard by some Can do dynamic testing when muscle in motion Tendon hypoechogenicity or thickening Limitations: difficult to visualize entire RC MRI: conservative therapy fails radiopaedia.org

18 RC Treatment Acute: Ice and cryotherapy NSAIDs for 5-7 days Rest PT: ROM exercises, stretching, strengthening Refer to Ortho: Conservative treatment fails in 6-9 months Tear RC or adhesive capsulitis Debridement, acromioplasty with debridement, or RC repair Usually no surgery if chronic tears Usually 6 months recovery after RC repair

19 RC Treatment Glucocorticoids: may also help to participate more in PT and do daily activities Topical glyceryl trinitrate: causes vasodilation Experimental: Topical NSAIDs Hyperthermia machines: thought to increase local blood flow Extracorporeal shock wave therapy: calcific tendinopathy Platelet rich plasma

20 Case 2 58 year old male who has right shoulder pain for 6 months No specific injury Construction worker and used to play baseball Pain with abduction past 90 degrees but normal passive ROM and strength Positive Neer and Hawkin tests

21 Impingement Compression of structures around GH joint that occur with shoulder elevation 3 types: subacromial, internal, and coracoid Primary or secondary Most common cause in middle age men Risk factors: Repetitive activities of the shoulder Older age Instability and laxity AC joint pathology

22 Impingement Movement of the shoulder can compress surrounding structures (bursa, labrum, biceps, RC) against acromion, OA changes, and coracoacromial arch

23 Impingement Neer described 3 stages Edema and hemorrhage (usually <25 years old) Fibrosis and tendinopathy (25-40 years old) RC/biceps rupture, bony change/spurs (>40 years old) Increased translation of humeral head Acromion morphology Decreased distance between acromion and humeral head Osteophytic change of AC joint Throwing: impingement of superior and posterior labrum and RC with ER, extension, and abduction With anterior translation of humeral head, which can be accentuated with GH instability

24 Impingement Symptoms are similar to RC tendinopathy Throwers may have pain and stiffness in the late cocking phase or early acceleration phase May have posterior shoulder pain

25 Impingement PE: similar to RC tendinopathy Neer and Hawkin maneuvers are sensitive to impingement Atrophy and asymmetry Limited ROM due to pain but usually good strength unless chronic Throwers may have increased laxity and tenderness posteriorly

26 Impingement Imaging X-rays usually not needed MSK ultrasound can help in evaluating tendons, muscles, and bursas MRI can help to identify inflammation of subacromial structures, compression by bone spurs, AC joint pathology, and low lying acromion

27 Impingement Treatment Initial management similar to RC injury Overhead thrower should refrain from throwing for 2-4 weeks, while doing PT Can start graded return to throwing when symptoms resolve Referring to Ortho is similar to RC injury but if laxity is present, capsular repair may be done Subacromial or subcoracoid decompression

28 Case 3 50 year old female with history of diabetes came in with left shoulder pain after falling 3 months ago Taking NSAIDs and resting but the pain was so significant that she was not moving her shoulder Wakes her from sleep Active and passive ROM limited in all directions

Adhesive Capsulitis Defined by AAOS as a condition of varying severity characterized by the gradual development of global limitation of active and passive

29 Adhesive Capsulitis Defined by AAOS as a condition of varying severity characterized by the gradual development of global limitation of active and passive shoulder motion where radiographic findings other than osteopenia are present. Also has severe shoulder pain Usually in 50s and 60s Women > Men eorthopod.com

30 Adhesive Capsulitis Etiology: idiopathic but usually due to other conditions RC tears, proximal humeral fractures, shoulder surgery or other surgeries Risk factors: DM, thyroid disease, prolonged immobilization, stroke, autoimmune disease Pathophysiology is not completely clear but may involve inflammation initially and then fibrosis Seems to affect anterosuperior joint capsule, coracohumeral ligament, and RC interval

31 Adhesive Capsulitis 3 phases: Initial phase with development of diffuse, severe, and disabling pain that is worse at night and increasing stiffness (2-9 months) Intermediate phase with stiffness and severe loss of shoulder motion but less pain (4-12 months) Recovery phase with gradual return of ROM (5-24 months to complete) Pain worse at night and causes global stiffness that affects daily activities

32 Adhesive Capsulitis PE: stiff and painful GH joint Reductions in BOTH active and passive ROM in 2 or more planes ER and abduction most affected Firm, painful, and premature end to passive ROM Injection test: active movement restriction and palpable, painful end with passive ROM after injecting lidocaine

33 Adhesive Capsulitis X-rays and MRI: limited use, consider to rule out other conditions MRI can show capsular thickening, reduced capsular volume, and hypointense granulation/fibrous tissue Ultrasound can show thickening of coracohumeral ligament and soft tissues of RC interval, increased fluid in the tendon sheath of the long head of the biceps, and increased vascularity around intra-articular portions of biceps tendon and coracohumeral ligaments

34 Adhesive Capsulitis Treatment Usually self limited but may not have complete resolution in some patients Can use NSAIDs for pain control First few months: shoulder rest with gentle ROM exercises cortisone injection and more aggressive ROM exercises; consider PT Reassess every 2-3 months and may consider manipulation under anesthesia or arthroscopic lysis of adhesions (if not improved 4-6 months) months: refer to Ortho

35 Adhesive Capsulitis Treatment One study showed improvement in pain and function after PO steroids but this was not maintained past 6 weeks (may not outweigh risks) Patients who receive injections early in their course may have more benefit, probably due to reduction in synovitis In a study, injections with PT > injections alone Intra-articular dilation (distension): anesthetic with infusion of saline to dilate GH capsule

36 Case 4 17 year old football player who has right shoulder pain for 2 weeks Started after being tackled onto his right side Still able to play but has pain, especially with overhead activities Normal ROM and strength but has pain with some of these maneuvers Positive O Brien and Crank tests

Labral Tears Labrum is part of cartilaginous ring that extends anterior and posterior to the biceps insertion Helps with the depth of the shallow glenoid increases humeral head contact

37 Labral Tears Labrum is part of cartilaginous ring that extends anterior and posterior to the biceps insertion Helps with the depth of the shallow glenoid increases humeral head contact and stability Risks: overhead sports, older age, trauma, overuse SLAP: superior labrum anterior to posterior Bankart: anterior inferior tear s/p dislocation

38 Labral Tears Associated with instability, RC tears, and cysts Humeral translation and traction on the biceps and capsular ligaments Snyder Types: I: fraying of superior labrum but biceps and labrum are still intact; degenerative II: superior labrum and biceps are detached; avulsion Posterior and posterior/anterior type II = throwers III: bucket-handle tears of superior labrum but biceps anchor is still attached to glenoid IV: bucket handle tear of superior labrum extends into biceps tendon

39 I: degenerative, superior labrum but attached biceps II: detachment of superior labrum and biceps III: bucket handle tear of superior labrum but attached biceps IV: tearing of superior labrum into biceps

Labral Tears Traumatic: FOOSH, hyperextension, seat belt Overuse accentuates internal impingement Symptoms: painful click, popping, catching, pain with overhead

40 Labral Tears Traumatic: FOOSH, hyperextension, seat belt Overuse accentuates internal impingement Symptoms: painful click, popping, catching, pain with overhead activities and acceleration PE: positive O Brien and Crank tests; may have provocative biceps testing with anterior tears MRI is dx modality of choice

41 Labral Tears Treatment Conservative treatment: NSAIDs, rest, PT Stretch posterior structures; RC strengthening; scapular stabilization Surgery: if conservative treatment fails Usually debridement for types I and III Type II in younger athletes may have repair Biceps tenotomy or tenodesis and repair in IV Post-op: immobilization for 3-4 weeks, followed by strengthening RTP 3-6 months

42 Questions?

43 Summary Physical Exam Special Tests Think of common problems

44 References Hansen, John. Netter s Clinical Anatomy, Second Edition Saunders, an Imprint of Elsevier Inc. Simons, Stephen and David Kruse. Rotator Cuff Tendinopathy. Up To Date. Accessed November 24, Simons, Stephen, Kruse, David, and J Bryan Dixon. Shoulder Impingement Syndrome. Up To Date. Accessed November 24, Prestgaard, Tore. Frozen Shoulder (adhesive capsulitis). Up To Date. Accessed November 24, O Connor, Francis G., et al. ACSM s Sports Medicine, A Comprehensive Review Wolters Kluwer, Lippincott Williams and Wilkins. Madden, Christopher C., et al Netter s Sports Medicine Saunders, an Imprint of Elsevier Inc. Harrast, Mark, and Jonathan Finnoff. Sports Medicine, Study Guide and Review for Boards Demos Medical Publishing.

Review shoulder anatomy Review the physical exam of the shoulder Discuss some common causes of acute shoulder pain Discuss some common causes of

Review shoulder anatomy Review the physical exam of the shoulder Discuss some common causes of acute shoulder pain Discuss some common causes of chronic shoulder pain Review with some case questions Bones: